HospitalInspections.org

.
Based on document review and staff interview, the facility failed to test and maintain the emergency electrical generator in accordance with §482.15(e)(2), §483.73(e)(2), §485.625(e)(2). Failure to properly test and maintain the emergency electrical generator could result in a failure of the generator in the event of an emergency. The deficiency affected the emergency preparedness plan.

The findings were:

Document review on 06/02/22 starting at 1:00 PM revealed that the emergency electrical generator lead-acid batteries were not being tested monthly. Documentation reveal that neither specific gravity testing, nor conductance testing, was being performed for the emergency electrical generator batteries.

Interview with facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.
.

.
Based on observation and staff interview, the facility failed to properly lock doors located in the means of egress in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly lock doors located in the means of egress could hinder to egress, which could result in injury or death in the event of an emergency. The deficiencies affected three (3) of multiple egress doors utilized by patient, staff, and visitors.

The findings were:

(1) Observation on 06/01/22 at 11:35 AM revealed a set of cross corridor doors, adjacent to the kitchen, with an exit sign located above them. Observation of the cross corridor doors revealed that the doors were locked and the only means of unlocking the doors was with a card reader intended for staff only. Observation of the opposite side of the doors also revealed an exit sign and revealed that the only means of unlocking the doors was by a motion sensor located above them. Doors within the required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key unless otherwise permitted by the Life Safety Code.

Interview with the facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.2.2.2.4


(2) Observation on 06/01/22 at 11:56 AM revealed a sliding door to the trauma rooms located in the ER department. Observation of the sliding door revealed a lock on the door that could be engaged from the ingress side of the door without the use of a key, but would require a key in order to unlock from the egress side of the door. Interview with the Facilities Manager, CEO, and CCO at the time of the observation revealed that it is currently not the intention of the facility to use the trauma rooms as a place for securing patients that pose a security threat. Doors within the required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key unless otherwise permitted by the Life Safety Code, including the means to secure a patient that may pose a security threat.

Interview with the facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.2.2.2.4, 18.2.2.2.5.1
.

.
Based on observation and staff interview, the facility failed to maintain the means of egress in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain the means of egress could hinder egress, which could result in injury or death in the event of an emergency requiring evacuation. The deficiency affected one (1) of multiple corridors used by staff, patients, and visitors.

The findings were:

Observation on 06/01/22 at 12:15 PM revealed a corridor located adjacent to the med/surg wing and OB wing, and open to the ER Department. Observation of the corridor revealed multiple instances of wheeled medical equipment located in the required egress width. Wheeled equipment shall be permitted in the required egress width provided it does not reduce the clear, unobstructed width to less than 60 inches, relocation of the equipment is addressed in the fire safety plan and training program, and the equipment is either in-use, medical emergency equipment not in-use, or is a patient lift or transport.

Interview with the facilities manager and CEO at the time of the observation stated that they did not believe that removal of the equipment was part of the fire safety plan or training program. The facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.2.3.4(4)
.

.
Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly protect hazardous areas could result in injury or death in the event of a fire. The deficiencies affected three (3) of multiple hazardous areas.

The findings were:

(1) Observation on 06/01/22 at 11:12 AM revealed a gift shop storage room located adjacent to the main lobby area. Observation of the gift shop storage room revealed that it was over 50 s.f. in size and being used to store combustible materials but the doors were not equipped with an automatic door-closing device. Storage rooms containing combustible storage that are greater than 50 s.f. in area shall have an automatic or self-closing door.

Interview with the facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 Table 18.3.2.1, 18.3.6.3.11


(2) Observation on 06/01/22 at 11:45 AM revealed an equipment storage room located in the ER department. Observation of the room revealed that it was labeled as being protected by a 1-hour fire barrier however, it was observed that the door to the room was not labeled as a 45 minute fire door. Storage rooms containing combustible material and over 100 s.f. in area shall be protected by a 1-hour fire barrier which requires a listed and labeled 45 minute fire rated door.

Interview with the facilities manager at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 Table 18.3.2.1, Table 8.3.4.2


(3) Observation on 06/01/22 at 2:00 PM revealed a sterile storage room containing combustible materials located in the OR Suite. Observation of the sterile storage room revealed a door that opened into the sterile core area that was not equipped with a door closer. Observation of the room revealed that it is protected by a 1-hour fire barrier and the door to the sterile core area was 45 minute rated. Doors located in fire barriers shall be self-closing or automatic-closing.

Interview with the facilities manager at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 Table 18.3.2.1, 8.3.3.3
.

.
Based on observation and staff interview, the facility failed to protect cooking facilities in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly protect cooking facilities could result in injury or death in the event of a fire. The deficiency affected one (1) of one (1) kitchen.

The findings were:

Observation on 06/01/22 at 11:22 AM revealed a gas cook-top under a commercial exhaust hood located in the facility's kitchen. Observation of the cook-top revealed that no means was provided to ensure it is returned to the approved location after being moved. Cooking appliances requiring fire-extinguishing protection shall be provided with a means of return to the approved location after being moved for cleaning or maintenance purposes.

Interview with the facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.3.2.5.5, 9.2.3; 2011 NFPA 96 12.1.2.3
.

.
Based on document review and staff interview, the facility failed to test and maintain the fire alarm system in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to properly test and maintain the fire alarm system could result in a failure of the system which could result in injury or death in the event of a fire. The deficiencies affected one (1) of one (1) fire alarm system.

The findings were:

(1) Document review on 06/02/22 starting at 11:30 AM revealed that the fire alarm system was not being activated every month. Document review revealed multiple months over the last twelve (12) months where the fire alarm system was not activated. The fire alarm system shall be activated on a monthly basis to ensure it is working properly.

Interview with facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.3.4.1, 9.6.1.3; 2010 NFPA 72 Table 14.4.5(24)


(2) Document review on 06/02/22 starting at 11:30 AM revealed that the alarm notification devices were not individually identified on the test report. Document review revealed that the alarm notification devices were tested but they were not listed out with location descriptions as required on the test report. The test report for the alarm notification devices shall list out all devices and include a location description and pass/fail checkoff.

Interview with facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.3.4.1, 9.6.1.3; 2010 NFPA 72 Table 14.4.5(20), 14.6.2.4
.

.
Based on document review and staff interview, the facility failed to test and maintain the fire sprinkler system in accordance with the 2012 NFPA 101, Life Safety Code, and 2011 NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. Failure to properly test and maintain the fire sprinkler system could result in a failure of the system, which could result in injury or death in the event of a fire. The deficiencies affected one (1) of one (1) fire sprinkler system.

The findings were:

(1) Document review on 06/02/22 starting at 11:30 AM revealed that the fire sprinkler system backflow preventer was not tested and inspected in the last 12 months. A backflow preventer that is associated with the fire sprinkler system shall be tested annually.

Interview with facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.3.5.1, 9.7.1.1; 2011 NFPA 25 13.6.2.1


(2) Document review on 06/02/22 starting at 11:30 AM revealed that the pre-action system that protects the MRI room did not have it's gauges recalibrated or replaced in the last 5 years. Gauges associated with the fire sprinkler system shall be recalibrated or replaced every 5 years.

Interview with facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.3.5.1, 9.7.1.1; 2011 NFPA 25 5.3.2.1
.

.
Based on observation and staff interview, the facility failed to protect corridors in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly protect corridors could result in smoke passing into the corridor which could result in injury or death in the event of a fire. The deficiency affected one (1) of multiple corridors used by staff, patients, and visitors.

The findings were:

Observation on 06/01/22 at 10:32 AM revealed a transfer grill located in the door to the IT closet that is adjacent to the administrative area. Observation of the transfer grill revealed that it would allow for the passage of smoke into the corridor. Transfer grilles shall not be used in corridor walls or doors unless in spaces that do not contain flammable or combustible materials.

Interview with the facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.3.6.4.1, 18.3.6.4.2
.

Based on observation and staff interview, the facility failed to maintain smoke barriers in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain smoke barriers could result in smoke passing from one smoke compartment to another which could result in injury or death in the event of a fire. The deficiency affected one (1) of two (2) smoke barriers.

The findings were:

Observation on 06/02/22 at 10:27 AM revealed unprotected penetrations located in the smoke barrier that runs along the west wall of the outpatient surgery recovery suite. Observation of the smoke barrier, above the ceiling of the cross corridor doors labeled "500E", revealed there were unprotected conduit and structural penetrations. Penetrations of a smoke barrier shall be protected by a system or material capable of restricting the transfer of smoke.

Interview with the facilities manager at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.3.7.3, 8.5.6.2
.

.
Based on observation and staff interview, the facility failed to maintain smoke barrier doors in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain smoke barrier doors could result in smoke passing from one side of the barrier to the other which could result in injury or death in the event of a fire. The deficiencies affected one (1) of two (2) smoke barriers.

The findings were:

(1) Observation on 06/02/22 at 10:49 AM revealed an unrated door in the smoke barrier that runs along the west wall of the outpatient surgery recovery suite. Observation of the door located in the smoke barrier that opens into the outpatient surgery recovery suite revealed that the door was not affixed with a label to confirm it is at least 20 minute fire rated, and the vision panel was not marked to confirm it is fire rated. Doors located in smoke barriers shall be at least 20 minute rated with a label permanently affixed and the vision panel shall be permanently marked.

Interview with the facilities manager at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.3.7.6, 18.3.7.10


(2) Observation on 06/02/22 at 10:51 AM revealed an unrated door in the smoke barrier that runs along the west wall of the outpatient surgery recovery suite. Observation of the door located in the smoke barrier that opens into the X-Ray Equipment room revealed that the door was not affixed with a label to confirm it is at least 20 minute fire rated. Doors located in smoke barriers shall be at least 20 minute rated with a label permanently affixed.

Interview with the facilities manager at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.3.7.6
.

.
Based on document review and staff interview, the facility failed to test and maintain the HVAC system in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 80, Standard for Fire Door and Other Opening Protectives. Failure to properly test and maintain the HVAC system could result in a failure of the system, which could lead to injury or death in the event of a fire. The deficiency affected all fire dampers in the facility.

The findings were:

Document review on 06/02/22 starting at 11:30 AM revealed that the facility had renovated it's HVAC system as part of its addition and renovation project. Documentation revealed that a large number of fire dampers were installed as part of the renovation that had spaces completed beginning May of 2020, but no evidence was available to demonstrate that dampers had been tested after being installed. Fire dampers shall be inspected and tested within 1 year of installation.

Interview with facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.5.2.1; 2010 NFPA 80 19.4.1
.

.
Based on document review and staff interview, the facility failed to test and maintain elevators in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly test and maintain elevators could result in a failure of the elevator which could injury or death in the event of an emergency. The deficiency affected one (1) of one (1) passenger elevator.

The findings were:

Document review on 06/02/22 starting at 11:30 AM revealed that the passenger elevator firefighter emergency operation controls were not being tested monthly. Elevators with firefighter emergency operation controls shall be tested monthly in accordance with ASME A17.1.

Interview with facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 18.5.3, 9.4.6.2
.

.
Based on observation and staff interview, the facility failed to properly install an emergency electrical generator in accordance with the 2012 NFPA 99, Health Care Facilities, and 2010 NFPA 110, Standard for Emergency and Standby Power Systems. Failure to properly install an emergency electrical generator could result in injury or death in the event of an emergency. The deficiency affected one (1) of two (2) emergency electrical generators.

The findings were:

Observation on 06/01/22 at 3:00 PM revealed that the emergency electrical generator located outside did not have an emergency power-off switch located outside of the generator's housing. All emergency electrical generators shall be provided with a remote manual stop located on the premises.

Interview with facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 99 6.4.1.1.6.1; 2010 NFPA 110 5.6.5.6
.

.
Based on document review and staff interview, the facility failed to test and maintain the essential electrical system (EES) in accordance with the 2012 NFPA 99, Health Care Facilities, and 2010 NFPA 110, Standard for Emergency and Standby Power Systems. Failure to properly test and maintain the EES could result in a failure of the system which could injury or death in the event of an emergency. The deficiency affected two (2) of two (2) EES.

The findings were:

Document review on 06/02/22 starting at 11:30 AM revealed that the emergency electrical generator lead-acid batteries were not being tested monthly. Documentation reveal that neither specific gravity testing, nor conductance testing, was being performed for the emergency electrical generator batteries. Lead-acid batteries associated with the emergency electrical generator shall be tested monthly for either specific gravity or for conductance.

Interview with facilities manager at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CCO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 99 6.4.1.1.6.1; 2010 NFPA 110 8.3.7.1